Kernow Clinical Commissioning Group and Age UK have said they hope to expand an integrated care scheme for older people with multiple conditions into the west of Cornwall following initial trials.

The Newquay Pathfinder, piloted by the commissioning group and supported by Age UK, provides joined up care across the NHS and social services, and won the HSJ award for Managing Long Term Conditions in London this week.

Age UK Cornwall's Tracey Roose said, "We are working together to remove the barriers between health, social care and the voluntary sector to improve the quality of life of people in Penwith. We have delivered some great results together in Newquay and we want to build on that experience to involve more partners and more older people in the west of Cornwall."

The plan is now being scaled up to include 1000 patients in Cornwall. The charity is hoping to expand it to three other regions by March 2014.

The scheme involves an Age UK staff member or highly trained volunteer acting as the key link, listening to the older person's needs and desires so that, together, they can draw up a care plan which suits their life and will help them maintain their health and well-being.

Typically, the plan includes physical and mental health needs including falls prevention support, exercise groups, social care, social clubs and activities in addition to helping older people maximise their income through information and advice.

NHS Kernow's managing director Joy Youart said: "It is about listening to the person's story and making everything fit around helping the person live the life they want to live. We are now able to wrap services around a person to ensure we are no longer just reactively responding to their needs but are instead helping them to manage their condition in their own homes."

The scheme is in its infancy in that only 100 people in Cornwall have been helped so far. But Age UK says the results are extremely promising, with quality of life, confidence and wellbeing of those on the pilot up 27 per cent, and a 35 per cent reduction in emergency hospital admissions.

Tom Wright, chief executive of Age UK said  "The pathway not only shows how successful integrated care can be but also demonstrates the huge contribution voluntary organisations can make to improving and maintaining the health of older people and to relieving the pressures on hospitals. We've already started work on extending the model to other parts of the country and we believe it has the potential to radically improve the lives of many older people across the UK."